793289

research-article2018
JHPXXX10.1177/0022167818793289Journal of Humanistic PsychologyJohnstone and Boyle

Diagnostic Alternatives
Journal of Humanistic Psychology
1­–18
The Power Threat © The Author(s) 2018
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DOI: 10.1177/0022167818793289
https://doi.org/10.1177/0022167818793289
An Alternative journals.sagepub.com/home/jhp

Nondiagnostic
Conceptual System

Lucy Johnstone1 and Mary Boyle2

Abstract
This article summarizes the results of a recently published project to develop
a conceptual system incorporating social, psychological, and biological
factors as an alternative to functional psychiatric diagnosis. The principles
underlying the Power Threat Meaning Framework are briefly described,
together with its major features and differences from diagnostic approaches.
These include the assumptions that what may be called psychiatric symptoms
are understandable responses to often very adverse environments and that
these responses, both evolved and socially influenced, serve protective
functions and demonstrate human capacity for meaning making and agency.
We describe how the elements of the Power Threat Meaning Framework
interact to restore links between environmental threats and threat
responses, and to enable us to outline some probabilistic Provisional General
Patterns, grouped by personal, social, and cultural meaning, describing what
people do, not the “disorders” they “have.” We conclude by outlining some
implications of the Framework for narrative construction and for thinking
about distress across cultures.

1Consultant Clinical Psychologist and Independent Trainer, Bristol, UK

2University of East London, London, UK

Corresponding Author:
Lucy Johnstone, Consultant Clinical Psychologist and Independent Trainer, Bristol, UK.
Email: lucyjohnstone16@blueyonder.co.uk
2 Journal of Humanistic Psychology 00(0)

Keywords
psychiatric diagnosis alternatives, power threat meaning framework

In 2013, coinciding with the publication of the Diagnostic and Statistical

Manual of Mental Disorders, Fifth Edition (DSM-5; American Psychiatric
Association, 2013), the Division of Clinical Psychology (DCP) of the British
Psychological Society released a position statement “Classification of behav-
ior and experience in relation to functional psychiatric diagnoses: Time for a
paradigm shift.” Its central message was as follows:

The DCP is of the view that it is timely and appropriate to affirm publicly that
the current classification system as outlined in DSM and ICD, in respect of the
functional psychiatric diagnoses, has significant conceptual and empirical
limitations. Consequently, there is a need for a paradigm shift in relation to the
experiences that these diagnoses refer to, towards a conceptual system not
based on a “disease” model. (DCP, 2013, p. 1)

A number of recommendations were made, of which one was “to support

work, in conjunction with service users, on developing a multi-factorial and
contextual approach, which incorporates social, psychological and biological
factors” (p. 9). This article describes the outcome of a DCP-funded project to
take forward this recommendation. The project group members were Lucy
Johnstone (project lead), Mary Boyle (deputy lead), John Cromby, Jacqui
Dillon, David Harper, Peter Kinderman, Eleanor Longden, David Pilgrim,
and John Read. Six of the members are clinical psychologists, one is an aca-
demic psychologist, and two are survivor campaigners who also work profes-
sionally in research and training. The project also drew on the expertise of a
consultancy group of eight service users/carers, a group of critical readers
and other specialists, and research and editorial assistance from Dr Kate
Allsopp.
Over a 5-year period, the project group developed a framework that aims
to provide a conceptual foundation for opening up new ways of understand-
ing and identifying patterns in mental distress, anomalous experiences, and
problematic behavior. We have named it the “Power Threat Meaning
Framework” (PTM). The project outcomes were published by the British
Psychological Society as two documents in January 2018, both openly avail-
able online. The first, the main publication (Johnstone & Boyle, 2018a, www.
bps.org.uk/PTM-Main), provides an analysis of the problems of medicaliza-
tion and psychiatric diagnosis and a detailed account of the underlying philo-
sophical principles, theories, and evidence supporting the PTM Framework.
Johnstone and Boyle 3

As well as describing the framework itself, it reports on the views of the

service user consultants who gave feedback on the framework as it developed
and concludes with suggestions about how it can be used not only for thera-
peutic interventions but also to support nondiagnostic practice in a range of
areas such as criminal justice reports and decisions, research, service com-
missioning and design, access to welfare payments, use of medication, and
public health initiatives. The document is inevitably dense, given its aim of
providing a solid intellectual foundation for a new conceptualization of men-
tal distress, but the framework itself can be read in a stand-alone form in a
shorter document, also available in hardcopy (Johnstone & Boyle, 2018b,
www.bps.org.uk/PTM-Overview). This describes the PTM Framework and
the Provisional General Patterns derived from it and offers a summary of the
principles and evidence from which the framework emerged. It also includes
appendices illustrating some of the ways in which nondiagnostic practice has
already been successfully adopted both within and beyond services.
Our longer term aim is to make these ideas and related resources freely
available in accessible forms beyond professional and service contexts, so
that anyone in distress can have access to alternative understandings and sup-
port. A two-page summary (PTM summary) is offered as a brief introduction
to the main principles of the framework for clinicians, service users, and oth-
ers, and a guided discussion suggests ways of reflecting on the ideas in the
framework as they may apply to particular individuals (PTM guided discus-
sion: see https://www.bps.org.uk/news-and-policy/introducing-power-threat-
meaning-framework for these and, in due course, other resources).
A brief description of the framework and some of its underlying principles
is given in this article. These are necessarily only headlines, and we encourage
interested people to read the framework itself in order to get a full picture.

Principles
Diagnosis in medicine is fundamentally an attempt to make sense of a per-
son’s presenting problems, to understand how they have come about and
what might help, by drawing on research into patterns/regularities in bodily
function and dysfunction. While basing diagnoses on these biological pat-
terns is appropriate for physical problems, psychiatric diagnosis is inherently
limited in its capacity to make sense of emotional/behavioral problems
because it largely draws on theoretical models that are designed for under-
standing bodies rather than people’s thoughts, feelings, and behavior. This
includes the ideas that people’s presenting emotional and behavioral prob-
lems represent “symptoms” of an internal pathology or dysfunction, that it
makes sense to search for biological “signs” associated with these symptoms,
4 Journal of Humanistic Psychology 00(0)

and that people can be placed in discrete categories represented by these

hypothesized clusters. The analogy is taken further, in suggesting drugs as a
first-line intervention. Challenging this view emphatically does not imply
dualism, since all human experiences are mediated by our biology. It simply
reflects the fact that the “rules” governing bodily functioning are not the
same as the “rules” governing the ways in which we feel, think, and act.
Alternatives to psychiatric diagnosis should therefore be based on theoretical
models and research designed for understanding people’s thoughts, feelings,
and behavior in their cultural, relational, social, and biological contexts.
Abandoning what we have called the “DSM mind-set” is not easy, since it
is deeply embedded not just in mental health services but also in fundamental
Western philosophical assumptions including, but not limited to, the separa-
tion of mind from body, thought from feeling, the individual from the social
group, and human beings from the natural world. These influential but not
universal worldviews also inform what can broadly be described as positiv-
ism, which tends to promote a view of human beings as objects acted on by
causal forces (Ingleby, 1981), rather than agents who have reasons for their
actions. This causal model can lead to reductionism—the view that complex
human experiences can be explained at their simplest, usually biological,
level such as “chemical imbalances.” It is also reflected in the idea of “mental
disorders” as having an independent existence, separate not only from the
person but also from historical time and place.
The positivist paradigm has led to major advances in medicine, science,
and technology. However, it is not well suited to understanding human emo-
tional distress. It is this philosophical basis, not just diagnosis and medical-
ization as such, that needs to be rethought if we are not to end up with
variations on the same unsatisfactory system, such as new terms for certain
“disorders” or new patterns still based on the belief that “mental disorders are
brain disorders,” as in the National Institute of Mental Health Research
Domains Criteria project (Insel, 2013).
There is also a recent trend for investigating links between particular
psychosocial events and circumstances (e.g., poverty or sexual abuse) and
particular outcomes (e.g., low mood or hearing voices) in the hope of iden-
tifying nonmedical causal pathways (e.g., Bentall et al., 2015). However,
failure to achieve enough distance from positivist assumptions means that
existing attempts to outline alternative causal patterns, whether biological
or psychological, have all foundered on what we have called the “every-
things” problem—as enumerated below.

•• Everything causes everything: Our main document summarizes a vast

and growing range of evidence for the causal impact of a whole range
Johnstone and Boyle 5

of relational and social adversities in all mental health presentations,

in marked contrast to the ongoing failure to provide evidence for pri-
mary biological factors. This has perhaps been demonstrated most
powerfully in the Adverse Childhood Experiences studies (Anda et al.,
2007; Dube et al., 2001; Felitti et al., 1998). Social inequality has been
shown to increase the likelihood of all kinds of mental health problems
as well as numerous other kinds of social problems and physical ill
health; attachment disruptions are common in all kinds of mental
health presentations; and themes such as guilt, shame, and self-blame
appear to underpin the whole range of difficulties (as well as being
common in general/nonpatient populations.) Conversely, the risk of
experiencing any specific type of mental health problem appears to be
raised by a whole range of social factors and adversities; 20 have been
identified for “psychosis” alone.
•• Everyone has experienced everything: The picture is further compli-
cated by the fact that few people in clinical (or other welfare/criminal
justice) settings have had single social disadvantages or adversities.
Indeed, experiencing one adversity is known to increase the likelihood
of experiencing more. Poverty is sometimes known as “the cause of
the causes” since it is likely to lead to a whole range of other problems
and to limit the ways in which their impact can be alleviated. There is
also the well-established phenomenon of revictimization, whereby
people who have experienced childhood abuse or neglect often experi-
ence further abuse in adulthood. Within this picture, we need to include
the possibility of revictimization by psychiatric services themselves
(something not addressed by this literature at all), in the form of
pathologizing, disabling, or coercive interventions that may create fur-
ther traumatization, disempowerment, and social exclusion.
•• Everyone suffers from everything: In diagnostic terms, this is known as
comorbidity. Almost every adult user of mental health services (and
other welfare services) struggles with anxiety, hopelessness, distrust,
low mood, low self-confidence, and relationship difficulties. A great
many also have unusual perceptual experiences and beliefs (depend-
ing on how broadly these are defined), use various forms of self-harm
(socially sanctioned or not), and control their eating. The same fre-
quently applies to children. Initial presentations often evolve and take
new forms over time, so that people collect more diagnoses.
•• Everything is a “treatment” for everything: This “everything” follows
from the others. Claimed specificities for particular drug regimes are
not borne out in practice; for example, “antipsychotics” have been rec-
ommended for diagnoses of schizophrenia, depression, anxiety, bipolar
6 Journal of Humanistic Psychology 00(0)

disorder, personality disorder, and attention deficit/hyperactivity disor-

der, while the indications for “antidepressants” are said to include bor-
derline personality disorder, depression, obsessive-compulsive disorder,
anorexia, panic and social phobia, among other problems (Timimi,
2014). Similarly, research suggests that the therapeutic relationship may
be as or more important than particular theoretical approaches or thera-
peutic techniques (Norcross, 2011). While none of this is necessarily a
problem for a nonmedical, nondiagnostic framework, it raises serious
questions about the legitimacy of medicalized, diagnostic approaches.

In summary, all types of adverse events and circumstances appear to raise

the risk for all types of mental health presentations (as well as for criminal
behavior and physical health problems). This appears to be mediated, for bet-
ter or worse, by all types of attachment relationships, all kinds of social sup-
port, all kinds of biological mechanisms, and all varieties of emotional and
cognitive styles.
Drawing on this and other evidence, we argue that while research seeking
very specific causal pathways between adversity and outcomes has useful
aspects, it fails to acknowledge that such pathways do not, and in all likeli-
hood cannot, exist in relation to human thoughts, feelings, and behaviors.
This is because causality in human affairs is generally highly probabilistic,
with an “on average” character; it is contingent, that is, the effects of any one
factor are mediated by and dependent on others; and it is synergistic in that
influences can magnify one another’s effects. In other words, the factors that
contribute to any aspect of human behavior, and their outcomes, are generally
multiple, complex, highly interactive and overdetermined, and, crucially,
always shaped by personal meaning and agency. This does not mean that
there are no regularities. However, it means that these will be seen most
clearly at a population or larger group level and that specific effects at the
individual level will rarely be predictable. It also implies letting go of “DSM
mind-set” assumption about universal causal laws and instead identifying
trends and associations, their directions of influence, and the processes that
might underlie them. A further important implication is that the kinds of pat-
terns that may be observed from this viewpoint will not only be very different
from diagnostic clusters but will also be used to illuminate individual distress
in a very different way.
With this in mind, we argue that any attempt to outline alternatives to the
current diagnostic system should have the following characteristics:

•• Be based on the identification of broad psychobiosocial patterns and

regularities as opposed to specific biological (or psychological) causal
mechanisms linked to discrete disorder categories
Johnstone and Boyle 7

•• Show how these patterns are evident to varying degrees and in varying
circumstances for all individuals across the lifespan
•• Not assume “pathology”; rather, describe coping and survival mecha-
nisms that may be more or less functional as an adaptation to particular
conflicts and adversities in both the past and the present
•• Integrate the influence of biological/genetic and epigenetic/evolution-
ary factors in mediating and enabling these response patterns
•• Integrate relational, social, cultural, and material factors as shaping the
emergence, experience, and expression of these patterns
•• Account for cultural differences in the experience and expression of
distress
•• Assign a central role to personal meaning, emerging out of social and
cultural discourses, material conditions, and bodily potentialities
•• Assign a central role to personal agency or the ability to exercise
choice within inevitable psychobiosocial constraints
•• Acknowledge the centrality of the relational/social/political context in
judgments about what counts as a “mental health” need or crisis in any
given case
•• Provide an evidence base for drawing on these patterns to inform indi-
vidual/family/group narratives
•• Offer alternative ways of fulfilling the service-related, administrative
and research functions of diagnosis
•• Suggest alternative language uses, while arguing that there can be no
one-to-one replacements for current diagnostic terms
•• Include meanings and implications for action in a wider community/
social/political setting

With these principles as a starting point, we draw extensively on relevant

psychological, social, and biological research to suggest a broad framework
for the preliminary identification of patterns that could be drawn on in mak-
ing sense of people’s difficulties. The framework’s core assumption is that
emotional distress and troubled or troubling behavior are intelligible
responses to life circumstances and adversities.

The Power Threat Meaning Framework

The main document analyzes and summarizes evidence on the social, bio-
logical, relational, and narrative aspects of the emergence, expression, and
persistence of mental distress. In summary, this framework for the origins
and maintenance of distress replaces the question at the heart of traditional
psychiatric practice, “What is wrong with you?” with four others:
8 Journal of Humanistic Psychology 00(0)

•• “What has happened to you?” (How is power operating in your life?)

•• “How did it affect you?” (What kind of threats does this pose?)
•• “What sense did you make of it?” (What is the meaning of these situ-
ations and experiences to you?)
•• “What did you have to do to survive?” (What kinds of threat response
are you using?)

In therapeutic, peer support or self-help work, these two questions may be

added:

•• “What are your strengths?” (What access to power resources do you

have?)

And to pull it all together, “What is your story?”

These key concepts and the evidence supporting them are elaborated as
follows:

1. The operation of POWER (embodied, legal, economic/material, rela-

tional, and ideological, both proximal and distal, with impacts that are
moderated by our available resources). In an extensive discussion of
the research, we highlight the fact that many of the adversities and
social inequalities associated with emotional and behavioral difficul-
ties involve the operation of these various forms of power. We also
describe how these processes are compounded in that different adver-
sities are related. For example, neglected children may become tar-
gets for bullying; discrimination against some minority ethnic groups
shows itself not just in their clustering in lower paid jobs and poorer
quality housing but also in humiliating and frightening personal expe-
riences of racial insults and abuse; this compounding of adversity
applies in general to members of subordinated groups such as women,
older people, or people with disabilities. As we noted, poverty is
sometimes known as “the cause of the causes” since it so often leads
to a whole range of other problems, whose impacts, like those of any
adversities, are not linear or additive but synergistic. We discuss the
well-established phenomenon of “revictimization” whereby people
who have experienced early abuse or neglect are more likely to expe-
rience further abuse. This includes retraumatization by mental health
services themselves. We place particular emphasis on ideological
power—power over language, meaning, and perspective—as part of
the operation of other forms of power.
Johnstone and Boyle 9

2. The kinds of THREAT that the negative operation of power may pose to
the individual, the group, and the community, with particular reference
to emotional distress, and the ways in which this is mediated by our biol-
ogy. There is consistent evidence about the conditions under which
people tend to struggle or flourish. These may be thought of as related to
“core needs”—broadly speaking, needs for safety and security; as
infants and children, close attachments to caregivers; positive relation-
ships within partnerships, families, friendships, and communities; to
have some control over important aspects of our lives, including our
bodies and emotions; to meet basic physical and material needs for our-
selves and our dependents; to experience some sense of justice or fair-
ness about our circumstances; to feel valued by others and be effective
in our social roles; to engage in meaningful activity and, more generally,
to have a sense of hope, meaning, and purpose in our lives. We are likely
to experience the potential or actual loss of any of these as threats.
3. The central role of MEANING (as produced within social and cul-
tural discourses and primed by evolved and acquired bodily responses)
in shaping the operation, experience, and expression of power, threat,
and our responses to threat. Meaning and narrative are the central
thread and final common pathway in the experience and expression of
mental distress at all levels, social, biological, and personal. For
example, child sexual abuse, poverty, and domestic violence are all
associated with anxiety, low mood, shame, withdrawal, and social
isolation. Indeed, themes such as social avoidance, guilt, shame, and
self-blame are common ingredients in all forms of distress. Meaning
is understood here as being constituted through both beliefs and feel-
ings, as well as through bodily reactions, and symbols. Shame, for
example, is constituted of both feeling and a belief about oneself, as
are humiliation, failure, worthlessness, and so on. Fear, trappedness,
panic, and despair are embodied emotions that arise out of beliefs
about one’s situation. The personal meaning of “What has happened
to you?” thus emerges as the joint product of circumstances, resources,
bodily potentialities, and social discourses, within which meaning is
both discovered and created. Equally, meaning can be communicated
through behavior, symbols, and bodily reactions, as well as verbally.
4. An individual (or family, group, or community) experiencing threat
arising within the PTM process may need to use certain evolved
THREAT RESPONSES, mediated through meaning-based bodily
capabilities, to protect themselves. Threat responses are shaped by our
earliest attachment relationships. Faced with threat, humans can draw
10 Journal of Humanistic Psychology 00(0)

on a spectrum of threat responses, which ensure emotional, physical,

relational, and social survival in the face of the negative impact of
power. We may call on any combination of these embodied responses
depending on the resources and cultural meanings available to us.
They may range from evolved, largely automatic biological responses
such as fight/flight/freeze/dissociate, to linguistically based or con-
sciously selected responses such as holding suspicious thoughts, self-
blame, shame, rage, self-harm, and controlling our eating. The latter
are likely to appear later in developmental terms, to be more open to
shaping by local meanings, and hence to be more culture-specific.

It is important to emphasize the fundamental differences between this and

the more traditional biopsychosocial model of mental distress. These are the
following:

•• Unlike (some versions of) the biopsychosocial model, there is no

assumption of pathology, and the “biological” aspects are not privi-
leged. They constitute one level of explanation, inextricably linked to
all the others.
•• Although a tripartite model is a convenient heuristic, the three ele-
ments are not independent but evolve out of one another. There is no
actual divide either within or across the proposed core aspects. The
individual does not exist, and cannot be understood, separately from
his or her relationships, community, and culture; meaning only arises
when social, cultural, and biological elements combine; and biological
capacities cannot be separated from the social and interpersonal
environment.
•• The capacity for creating meaning (within available discourses) and
the exercise of agency (within material and biosocial restraints) are
core attributes of human beings. “Meaning” is intrinsic to the expres-
sion and experience of all forms of emotional distress, giving unique
shape to the individual’s personal responses.
•• While most mental health work is aimed at the individual, we argue
that meaning and distress must also be understood at social, commu-
nity, and cultural levels. Thus, we see the PTM Framework as apply-
ing equally to understanding intervention and social action in a wider
sense as well as bringing social context into work with individuals.

Restoring the Links Between Threats and Threat Responses

The functional and strategic nature of responses to adversity means that they
cannot be understood separately from the circumstances in which they arose.
Johnstone and Boyle 11

One of the main aims of the PTM Framework is therefore to restore the links
between meaning-based threats and meaning-based threat responses.
In some situations, we already do this. It hardly needs stating that the
death of a loved one is experienced as loss and commonly evokes a reaction
of grief; absence of attachment figures is experienced as abandonment and
leads to anxiety and searching in young children; threat to physical safety
results in terror and a fight/flight/freeze reaction; and so on. However, we do
not usually ascribe pathology where the immediate psychosocial causal event
is obvious. We argue that the whole range of functional psychiatric “disor-
ders” (and many other difficulties) can be understood in this way once we
identify the meaning-based threats and restore their links with the protective
threat responses. To take just one example, researchers into “paranoia” have
commented that its well-established links to experiences of bullying, vio-
lence, discrimination, and unsafe environments render it “understandable,
and, indeed, adaptive” (Shevlin, McAnee, Bentall, & Murphy, 2015, p. 213).
However, behaviors and responses that promote survival in certain contexts
may subsequently become problematic in their own right, for the person
themselves and/or for those around them.
There are a number of reasons why these links may not be obvious.
Commonly, the threat (or operation of power) is distant in time, and perhaps
not even available to conscious memory, even though the threat response is
still active. The threat may be less obvious because it is subtle, cumulative,
and/or socially acceptable. The threats may be so numerous, and the responses
so many and varied, that the connections between them are confused and
obscured. The threat response may take an unusual or extreme form that is
less obviously linked to the threat—for example, apparently “bizarre” beliefs,
hearing voices, self-harm, and self-starvation. The person in distress might
have become accustomed to disavowing the possibility of a link, because
acknowledging it might have felt dangerous, stigmatizing, or shaming. And
when contact with services has been made, mental health professionals are
trained to obscure the link by the application of a diagnosis that imposes a
powerful expert narrative of individual deficit and “illness.”
Threat responses are most usefully considered not as discrete “symptoms”
or complaints but in terms of the main functions they serve. They are strate-
gies that link to core human needs to be protected, valued, find a place in the
social group, and so on. Their function will vary from person to person,
although some within-culture commonalities can be expected (e.g., in Western
settings, restricted eating is often associated with a need to take control). In
addition, the same threat response may serve multiple purposes for a single
individual. Thus, self-harm may be used simultaneously as self-punishment,
communication, release of feelings, and a means of eliciting care. All of these
strategies represent people’s attempts—conscious or otherwise—to survive
12 Journal of Humanistic Psychology 00(0)

the negative impacts of power by using the resources available to them. Rather
than being “diagnosed” as passively suffering biological or psychological
deficits, we suggest that service users (and all of us) can be recognized and
validated as using threat reactions for protection and survival.

Identifying Provisional Patterns Within the Power Threat

Meaning Framework
As discussed, patterns and causality in relation to human behavior, experi-
ence, and distress are best understood as highly probabilistic, with influences
operating contingently and synergistically—that is, in ways that it is often
impossible to predict accurately in advance. This is complicated further by
the fact that all the elements in any pattern are shaped by culture, meaning,
and developmental stages. Since these aspects are constantly changing,
sometimes slowly, sometimes more rapidly, patterns will always be provi-
sional and to an extent local—that is, they have forms of expression that are
specific to an individual, a social group, a community, a culture, and a histori-
cal period. There are, therefore, no separate “culture-bound syndromes”—all
expressions of distress are culture bound, as are all judgments about what
constitutes problematic, or adaptive, behaviors and reactions. And if cultural
and personal meaning also mediate the impact of any given situation or event,
it may be impossible to predict precise outcomes in terms of actions or
expressions of distress.
This does not mean that no regularities exist. However, our central assump-
tion is that these are not, as in medicine, fundamentally patterns in biology.
Rather, they are patterns organized by personal, social, and cultural meanings.
We suggest that specific threat responses and their origins within a PTM
Framework can be tentatively grouped into broad, provisional, evidence-based
patterns of embodied, meaning-based threat responses to the negative opera-
tion of power. They are expressed as verbs not nouns—descriptions of what
people do, not what they have. In another departure from diagnostic patterns,
they cut across diagnoses, across specialties, and across the usual divisions of
“ill” or “well,” “mad or sane,” in recognition that all of us are subject to the
negative operation of power in some areas of our lives, and all of us struggle at
times to survive and meet core human needs. The provisional identification of
these evidence-based patterns provides a context for the co-construction of
individual narratives, as well as suggesting alternatives to diagnosis for cluster-
ing/administrative/legal/service planning/research purposes.
We describe some provisional evidence-based general patterns that emerge
when viewed through a PTM lens. They are not presented as a definitive and
complete set; rather, they offer a starting point for further research and
Johnstone and Boyle 13

development. However, they are solidly based in theory and evidence. Each
general pattern includes a range of possible threat responses (e.g., hypervigi-
lance, hearing voices, restricted eating, etc.) grouped in terms of the function
they are serving. Conversely, each type of threat response may appear within
several different general patterns and may serve a range of different functions.
As described further in the project documents, these patterns provide a basis
for validating and supporting narratives of distress at all levels, from individ-
ual to community, as well as suggesting alternative ways of fulfilling the other
purposes for which psychiatric diagnosis is currently used (see Chapter 8 of
the main document).

Cultural Perspectives: North and South

The PTM Framework provides a possible solution to the hitherto irresolv-
able dilemma about the application of Western psychiatric classification sys-
tems to non-Western cultures and expressions of distress, both within the
United Kingdom and around the world. The framework predicts and allows
for the existence of widely varying cultural experiences and expressions of
distress without positioning them as bizarre, primitive, less valid, or exotic
variations of the dominant diagnostic paradigm. The same applies to histori-
cal phenomena such as “hysteria.” Viewed as a meta-framework that is
based on universal evolved human capabilities and threat responses, the core
principles of PTM apply across time and across cultures. Within this, open-
ended lists of threat responses and functions allow for an indefinite number
of locally and historically specific expressions of distress, all shaped by pre-
vailing cultural meanings. From this viewpoint, as we have noted, there are
no separate “culture-bound syndromes”; rather, all expressions of distress
are culture bound.
As we have argued, examples of power operating at a proximal level
include adversities such as abuse, neglect, discrimination, exclusion, and vio-
lence. At a more distal level, socioeconomic structures influence the preva-
lence and type of adversities. In the Global North, but increasingly in the
Global South as well, these adversities arise within the context of industrial-
ization and its related socioeconomic structures. These have brought many
advances, particularly in the fields of technology, science, and health care,
but there have also been costs and losses. Depending on the currently domi-
nant political ideology, industrialization implies varying degrees of income
inequality with all its well-documented destructive consequences for the
social fabric (Wilkinson & Pickett, 2010). Along with the work of many oth-
ers, our analysis suggests that socioeconomic structures influence social
norms, discourses, and ideological meanings in ways that serve and shape
14 Journal of Humanistic Psychology 00(0)

both the negative and the positive operation of power in line with certain
interests—social, economic, political, and so on.
It follows from all the above that the expressions and experiences of dis-
tress within a given society will be likely, at some level, to reflect the inability
(perceived or actual) to live up to its norms, values, and expectations, as
partly conveyed through social discourses and ideological meanings. Thus,
we might expect common patterns of distress in industrialized societies to
center around themes such as struggling to achieve in line with accepted defi-
nitions of success; separate and individuate from one’s family of origin; fit
expectations about body size, shape, and weight; fulfill wage labor roles;
meet normative gender expectations, including those relating to sexual orien-
tation; compete successfully for material goods; meet emotional and support
needs within a nuclear family structure; reconcile the values and expectations
of having a different culture of origin; persuade children to behave according
to received expectations; and so on. Similarly, we might expect to find com-
mon patterns of distress relating to the core human needs that are most likely
to be threatened by the negative impacts of industrialization, such as social
exclusion, marginalization, and isolation. Finally, we might expect to see an
increased risk of attracting a diagnosis as a response to experiences that chal-
lenge Western conceptions of personhood—for example, “nonrational”
beliefs, unusual spiritual beliefs, and experiences such as hearing voices that
do not fit with the notion of a unitary self.
Existing feelings of shame, self-blame, and deficit about the struggle to
live up to ideologically driven assumptions and expectations can be strongly
reinforced by receiving a psychiatric diagnosis. The unevidenced “disease”
model that is typically promoted in industrialized societies is associated with
much higher levels of stigma and lower expectations of recovery (Kvaale,
Haslam, & Gottdiener, 2013; Read, Haslam, Sayce, & Davies, 2006). This
loss of hope is self-fulfilling, and thus, the vicious circle is complete.
The evidence that “severe mental distress” often has much better out-
comes in the Global South where local healing rituals and practices are
used alongside, or in place of, diagnosis and medication (Davidson &
McGlashan, 1997; Warner, 2004) is entirely consistent with the PTM per-
spective, with its emphasis on social support and shared narratives—les-
sons that need to be rediscovered in industrialized societies, as the evidence
suggests. There is therefore no implication that the PTM Framework needs
exporting in the manner of another movement for global mental health.
Rather, we hope that the framework conveys a sense of respect for the
numerous nonmedical culturally specific ways in which individual and
community distress is expressed, experienced, and healed in the United
Kingdom and around the globe.
Johnstone and Boyle 15

PTM Narratives as a Source of Healing

As discussed, we believe that there is sufficient evidence to suggest a broad,
provisional set of response patterns, described as verbs not nouns: for exam-
ple, “surviving social exclusion, shame, and coercive power,” “surviving
defeat, entrapment, disconnection, and loss,” and “surviving rejection,
entrapment, and invalidation.” Individuals will vary in their fit or match to
them. Their main purpose is to provide evidence-based summaries that can
be used to support the development of personal narratives as a more effec-
tive way of fulfilling some of the claimed functions of diagnosis, such as
providing an explanation, having distress validated, facilitating contact with
others in similar circumstances, relief from shame and guilt, and conveying
hope for recovery.
Narratives can take various forms, one of which is psychological formula-
tion (Johnstone & Dallos, 2013), a popular and widespread practice in the
United Kingdom. However, the long-term aim is to make the knowledge and
evidence that supports the PTM Framework available and accessible to all, so
that it can be used to develop a narrative by anyone in distress, whether in
contact with mental health services and other agencies or not. We argue that
narratives of any kind will be more holistic, helpful, healing, empowering,
and evidence-based if they draw on all aspects of the PTM Framework. This
will necessarily involve a more explicit link to, and focus on, the many
aspects of the operation of power that are typically excluded by current con-
ceptualizations of distress, both medical and psychological.

Conclusion
The PTM Framework main publication stands at about 190,000 words and
may be a challenging read. It has certainly been challenging to write it. In
this article, it has only been possible to give a brief flavor of the arguments,
and the document itself is only intended as the first in a longer series of
projects that will support its further development. However, we hope that we
have conveyed some of the central aims of the framework, which are the
following: reinstating the multilayered role of power in the emergence of
distress, restoring the links between threat and threat response, suggesting
patterns that are organized by meaning not by biology, supporting the con-
struction of personal narratives as an alternative to diagnosis, and promoting
social action.
Since we are conceptualizing PTM as a meta-framework, which can be
used not just in its own right but also to inform more holistic and inclusive
versions of existing models and practices, it is compatible with many of the
16 Journal of Humanistic Psychology 00(0)

other articles in this series and the models and approaches they describe. We
hope that it will play a part in the much-needed radical shift toward nondiag-
nostic theory and practice, which has gathered speed and support since the
publication of DSM-5.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research,
authorship, and/or publication of this article.

Funding
The author(s) disclosed receipt of the following financial support for the research,
authorship, and/or publication of this article: Funding for this project was provided by
the British Psychological Society’s Division of Clinical Psychology.

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Author Biographies
Lucy Johnstone, DPsych, is a consultant clinical psychologist,
author of Users and Abusers of Psychiatry (2nd ed., Routledge,
2000), and coeditor of Formulation in Psychology and
Psychotherapy: Making Sense of People’s Problems (Routledge,
2nd ed., 2013) and A Straight-Talking Guide to Psychiatric
Diagnosis (PCCS Books, 2014), along with a number of other
chapters and articles taking a critical perspective on mental health
theory and practice. She is the former program director of the
Bristol Clinical Psychology Doctorate and was the lead author of Good Practice
Guidelines on the Use of Psychological Formulation (Division of Clinical Psychology,
18 Journal of Humanistic Psychology 00(0)

2011.) She has worked in adult mental health settings for many years, most recently
in a service in South Wales. She was lead author, along with Professor Mary Boyle,
for the Power Threat Meaning Framework, a Division of Clinical Psychology–funded
project to outline a conceptual alternative to psychiatric diagnosis, which was pub-
lished in January 2018. Lucy is an experienced conference speaker and lecturer, and
she currently works as an independent trainer. Her particular interest and expertise is
in the use of psychological formulation, in both its individual and team versions, and
in promoting trauma-informed practice.
Mary Boyle is Emeritus Professor of clinical psychology at the
University of East London, the United Kingdom, where she was
head of the masters and then doctoral program in clinical psychol-
ogy for more than 20 years. She also worked as a National Health
Service clinical psychologist in adult services and in women’s
health. Her main areas of interest are in critical clinical psychol-
ogy, especially in problems with medicalization of distress and
psychiatric diagnosis. She is the author of Schizophrenia: A
Scientific Delusion? (Routledge, 2002) and of many articles and chapters on medical-
ization and alternatives. She has also published widely on feminist approaches in
clinical psychology and women’s health, particularly in relation to disorders of sexual
development, sexual difficulties, contraception, and abortion, including Rethinking
Abortion: Psychology, Gender, Power and the Law (Routledge, 1997). With Lucy
Johnstone, Boyle was a lead author of the Power Threat Meaning Framework (2018),
a conceptual system, and alternative to psychiatric diagnosis, which offers a funda-
mentally different understanding of emotional and behavioral difficulties.